This study evaluated the social factors associated with non-prescription use of Tramadol among urban informal settlement dwellers aged 15–35 years from the Asokore Mampong Municipality, Ghana. Male respondents dominated our study. The limited female representation may be attributed to the high level of fear of the stigmatization attached to female drug users as deviants compared to their male counterparts in the Ghanaian socio-cultural setting. Our study identified that most respondents had poor perceptions about the use and purpose of Tramadol. Almost two-thirds of the total respondents thought Tramadol was meant for purposes other than for the treatment of moderate to severe pain under medical supervision. Approximately a third of the respondents had the right perception about the use of Tramadol for pain relief, although its use was without medical approval, which also constituted abuse. Ibrahim et al. [38] discovered a much higher misconception (90%) rate on the use and purpose of Tramadol in Nigeria. The outcome was quite surprising because, given the proportion of respondents who had some level of formal education (Table 1), the expectation was that they would be more enlightened to make the right judgment about the use and purpose of the painkiller.

Family or friends also emerged as the primary source of information about Tramadol to respondents. Other studies in Ghana have observed similar outcomes [9, 10, 39]. Peprah et al. [9], for instance, noted that relatives usually advertised the perceived off-label benefits of Tramadol to respondents and recommended it for experimentation. Perhaps most respondents heeded the advice from their family/friends due to familial and collegial ties and trust. The poor perception revealed by the majority of the respondents about the use and purpose of Tramadol could partly be blamed on the misinformation their families or colleagues (who may not be health professionals) fed them.

Our findings further showed that most respondents used non-prescription Tramadol for an energy boost. The results from Elliason et al. [39] in the Amenfi West District of Ghana, Ibrahim et al. [38], and Madukwe and Klein [40] in Nigeria support our findings. This implies that aside from the real reason for the use of the drug as a pain reliever, most respondents riskily continued to use the painkiller for non-health-related reasons. This outcome is also confirmed by the large community sample study in the UK, where 44% of participants reported using Tramadol for reasons other than for pain relief [41]. Since the use of Tramadol has proven to increase physical performance and attention [42], it may be a means by which respondents revitalize lost energy and delayed fatigability against the menial and energy-sapping work they mainly engaged in. However, due to Tramadol’s dependence risks [18], its continuous use represents a maladaptive coping mechanism for work-related stress.

Tramadol was easily accessible without medical prescription within the study communities. This observation is consistent with prior findings [2, 9, 13]. The ease with which the painkiller could be accessed may be linked to poor drug control and vigilance mechanisms by regulatory authorities [3, 6]. Most of the Tramadol brands on the African and Ghanaian open markets have been flagged as substandard and fake [3, 7, 19]. Most of the respondents likely patronized these fake doses due to their availability on the market.

The results from the multivariate regression analysis (after adjustment) showed that socio-demographic factors, including living arrangement, nativity status, length of stay in the study communities, and employment, were significantly associated with non-prescription use of Tramadol (Table 2). For instance, respondents who lived alone were 6.3 times more likely to subscribe to the non-prescription use of Tramadol than those who were partnered or lived with others. The outcome agrees with the study by Danso and Anto [27] among commercial drivers and their assistants in the Greater Accra Metropolis, Ghana. Migrants were 4 times more likely to engage in non-prescription use of Tramadol. Migrants may lack parental or spousal checks and balances, which have been reported to guard against the initiation and misuse of substances [43] since they are likely to live alone.

Respondents who lived in the study communities for 5–14 years had lower odds of non-prescription Tramadol use. These respondents may have adapted to cope better with the socio-economic challenges of their environment. This outcome is in tandem with the findings of prior studies by Danso and Anto [27]. Unemployed respondents also had higher odds of non-prescription use of Tramadol. This finding is similar to recent outcomes by Saapiire et al. [28] in Ghana and Azagba et al. [44] in the United States. Our finding could be explained by the stress hypothesis, which posits that emotional and psychological diseases, including joblessness, may expose people to drug use as a means of extenuating the stress source [45].

Since information flow is crucial in influencing behavior, we recommend that urban informal settling youth are well-sensitized to authenticate information about drugs, including Tramadol, from health professionals before responding to them. The public health division of the Ghana Health Service and the FDA should frequently collaborate to organize public education on drug use within the study communities. The adverse consequences of drug abuse, specifically Tramadol, should be duly emphasized. Again, the Municipal Authority should employ the services of occupational psychologists and counselors to educate them on healthier ways of coping with job-related and other socio-environmental stressors.

As a matter of urgency, we suggest that drug control agencies such as the FDA and Narcotic Control Board, together with the police, should be well-resourced by the central government to effectively trace, monitor, and clamp down on illegal importation, trade, and use of Tramadol. Unannounced inspections should be carried out in popular hideouts called bases or ghettos in the study communities where the drug is usually traded and used. We further encourage the promotion of parental and spousal ‘checks and balances’ in the study communities to shield against non-prescription use of Tramadol.

The Municipal Authority can liaise with the Ministry of Gender, Children, and Social Protection to design and implement measures to promote family integration/cohesion. For instance, pragmatic strategies should be mapped to target migration control, threatening family integration.

We finally recommend that the Municipal Assembly, in conjunction with appropriate authorities, develop and implement tailor-made poverty reduction strategies to ease the socio-economic burden of inhabitants within the study communities. For instance, efforts should be made to create sustainable and gainful job opportunities in these study areas.

The study has some limitations. First, using cross-sectional data/design made it difficult to draw causal relationships between the dependent and independent variables. Future studies may benefit from using longitudinal data and improve our understanding of the predictors of the non-prescription use of Tramadol in informal settlements. Given the subject’s sensitivity, social desirability bias and recall bias (due to the retrospective reporting) may be inevitable and undermine the findings’ veracity. The study nonetheless adds to the limited knowledge of drug use, specifically the novel Tramadol abuse in vulnerable populations, including urban informal settlements in Ghana.